Article Impact Level: HIGH Data Quality: STRONG Summary of Annals of Internal Medicine, ANNALS-24-03153. https://doi.org/10.7326/ANNALS-24-03153 Dr. Alexander A. Leung et al.
Points
- This study evaluated the effectiveness of the seated saline suppression test in confirming primary aldosteronism among 156 previously screened patients using treatment response as the diagnostic reference.
- Results showed significant overlap in post-test aldosterone levels between responders and nonresponders, indicating the test’s poor discriminatory power.
- The test demonstrated a low diagnostic accuracy with an AUC of 62.1 percent and weak likelihood ratios across commonly used aldosterone thresholds.
- The high false-negative rate of the SSST raises concerns about its use in routine confirmation, as it may delay treatment for eligible patients.
- Researchers suggest eliminating the SSST from standard protocols could improve diagnostic efficiency and enable quicker intervention for primary aldosteronism.
Summary
This study assessed the seated saline suppression test (SSST) diagnostic accuracy for confirming primary aldosteronism (PA) in patients who had previously screened positive for the condition. The study included 156 adults who underwent the SSST, which involved administering 2 L of saline intravenously over 4 hours while seated. The response to treatment, defined by blood pressure reduction, antihypertensive drug dose reduction, and biochemical normalization, was used as the reference standard to determine disease status. Sensitivity, specificity, positive, and negative predictive values were measured to evaluate the SSST’s performance.
The results showed that the SSST failed to discriminate between treatment responders and nonresponders. Post-SSST aldosterone concentrations overlapped significantly between responders (median 329 pmol/L [IQR, 227–525 pmol/L]) and nonresponders (median 255 pmol/L [IQR, 162–346 pmol/L]). The SSST’s ability to distinguish between response statuses had a low area under the curve (AUC) of 62.1% (95% CI, 45.1% to 79.1%), and the positive and negative likelihood ratios were similarly equivocal for aldosterone cutoffs ranging from 140 to 300 pmol/L. These results were consistent even after considering variations in treatment, hypokalemia, and laboratory assays.
The study concluded that the SSST has a high false-negative rate, meaning it could miss patients who would respond to treatment for PA. The reliance on this test as a confirmatory measure may lead to missed treatment opportunities and delays in diagnosis. The findings suggest that removing routine confirmatory testing with the SSST could improve diagnostic accuracy and shorten the time to effective treatment for primary aldosteronism.
Link to the article: https://www.acpjournals.org/doi/10.7326/ANNALS-24-03153
References Leung, A. A., Padwal, R. S., Hundemer, G. L., Venos, E., Campbell, D. J. T., Holmes, D. T., Orton, D. J., So, C. B., Przybojewski, S. J., Caughlin, C. E., Pasieka, J. L., Rabi, D. M., & Kline, G. A. (2025). Confirmatory testing for primary aldosteronism: A study of diagnostic test accuracy. Annals of Internal Medicine, ANNALS-24-03153. https://doi.org/10.7326/ANNALS-24-03153
